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<">UTH CONGRESS, 

2d Session. 



Calendar No. 142. 



HOUSE OF REPRESENTATIVES. 



I 



Report 
No. 616. 



WAR EXPENDITURES— GENERAL HOSPITAL NO. 21, AT 

AURORA, COLO. 



February 9, 1920. — Referred to the House Calendar and ordered to be printed. 

Mr. Graham of 1 llinois, from the .Select Committee on Expenditures 
in the War Department, submitted the following 

REPORT. 

[Relative to United States General Hospital No. 21, at Aurora, Colo.] 

Subcommittee No. 2, of the Select Committee on Expenditures in 
the War Department, requested subcommittee No. 1, of the same 
committee, to investigate certain complaints and matters relative 
to United States General Hospital No. 21, at Aurora, Colo. This 
investigation was conducted by Hon. Clarence F. Lea, of said sub- 
committee No. 1. The testimony taken by Mr. Lea will be found 
on pages 695 to 866, inclusive, of the records of the hearings of sub- 
committee No. 2. Mr. Lea has made his report to said subcommittee, 
which has been, by action of said subcommittee, adopted as its 
report, and submitted to the Select Committee on Expenditures. 
Said select committee nas, on motion, adopted said report as the 
report of said committee, and the same is now here presented to the 
House, and is as follows, to wit: 

Hon. John C. McKenzie, 

Chairman Subcommittee No. 2 — Camps, 
Select Committee on Expenditures in the War Department, 

House of Representatives. 
Dear, Sir: Pursuant to your request to investigate the general 
conditions and treatment and care of patients at the United States 
General Hospital No. 21, I submit the following report: 

I visited said hospital at Aurora, near Denver, and conducted 
said investigation on the 25th and 26th days of September, 1919. 

I visited different wards in the institution, the disciplinary bar- 
racks, the infirmary and kitchen, and had one- meal at the general 
mess with the patients. I took the testimony of about 35 witnesses, 
as now embodied in the printed records of your hearings. 



GENERAL HOSPITAL KO. 21, AT AURORA, COLO. 



r 



This hospital consists of 31 wards, conveniently arranged and well 
located over a liberal area. 

It was specially designed to accommodate tubercular patients 
from the military service. Its construction was begun in 1918; its 
first patients were received on the 17th of October of that year. 
The hospital was not fully equipped during the severe part of the 
winter of 1918-19, and was not entirely completed until June, 1919 
(pp. 779-783). 

About 500 patients were accommodated before the 1st of January, 
1919, and about 2,000 patients up to the 17th day of June, 1919 
(p. 774). 

Complaints charged that the quality of food provided for the 
patients was poor; frequently insufficiently cooked or overcooked; 
not properly seasoned; frequently served cold and in an uninviting 
way; the quantity was insufficient; that a low grade of milk was 
furnished; that the officers in authority arbitrarily refused the 
distribution of food from the outside to patients and that the dishes 
were not properly cleaned; that strait-jackets were used improperly; 
that patients were in some instances neglected; that the rules govern- 
ing the inmates of the disciplinary barracks were unnecessarily 
severe; and that the management was unjust and illiberal in the 
granting of passes to patients. 

THE FOOD. 

Proper food materials were supplied to the institution. While the 
quality of food supplied the patients varied, it was generally unsatis- 
factory for six or eight months after the opening of the hospital. 
Frequently it was only partly cooked, and more commonly it was 
overcooked; not well seasoned; served in an uninviting way; and by 
the time it reached the patients was cold or nearly so (pp. 726-727). 

The quantity of food supplied was sufficient. f 

These undesirable conditions of the food were primarily due to 
three reasons: First, indifferent and incompetent cooks; second, the 
method of serving: and, third, the lack of proper heating facilities 
and nonconducting food conveyors during the early months of the 
institution. 

Cooks and kitchen and dining-room help were obtained from the 
ranks and were largely limited-service men (p. 781). Cooks were 
selected because of hotel or restaurant or ordinary experience. They 
were not qualified to provide the food required for sick men, particu- 
larly for the delicate appetites of tubercular patients. 

There was a shortage of cooks and a pressing demand for their 
services outside of the Army at attractive salaries. Retention of 
these men in the hospital after the armistice and against their will, 
at the Army pay of cooks, created an indifferent and inefficient serv- 
ice, for which the patients in the institution suffered (pp. 728, 852, 

783). 

Patients who were able to do so took their meals at the general 
mess, which is centrally located. For many months the food for the 
whole meal was placed on the tables before the patients were admit- 
ted to the dining room. Frequently the food cooled off to such an 
extent as to largely lose its palatabilitv before the patients reached 
the tables (pp. 697, 726, 794). 

n; ••#* >. 

JKAfl J** 1920 



GENERAL HOSPITAL NO. 21, AT AURORA, COLO. 6 

•o 

The construction and equipment of the hospital was rushed to 
meet an emergency need. On .account of inability to get proper 
equipment, a temporary heating system was improvised by the use 
of boilers from a sugar factory and conveying pipes temporarily 
laid (p. 794). The result was insufficient heating capacity for the 
severe winter and the steam tables located in the various wards over 
the hospital ground did not receive a temperature sufficient to warm 
up or retain the heat of food delivered to the infirmary or to patients 

I who were unable to come to the general mess. 
The institution was supplied with a large quantity of skimmed 
milk, a portion of which was given to the patients for drinking pur- 
poses, and, of course, it did not contain the palatable or nutritive 
qualities of whole milk which should have been supplied tubercular 
patients. The patients are now supplied whole milk for drinking 
purposes (pp. 804, 759). 

Fortunately, these conditions were greatly improved prior to this 
investigation. A more satisfactory management of the Kitchen had 
been provided and at the time the hearing was held provision had 
been made for the employment of civilian cooks. 

The practice of placing food on the table before the patients 
entered the dining room was discontinued several months ago and a 
system substituted by which the patients eating at the general mess 
pass by a counter from which they are individually served directly 
from warm steam containers. 

The improvised heating system was discarded in the latter part of 
the winter and a modern system installed with sufficient capacity to 
provide heated steam tables in every ward from which food is dis- 
tributed directly to patients unable to visit the general mess (p. 795). 
Food conveyors with nonconducting containers have been provided 
under which food is now distributed to remote sections of the hospital 
at a satisfactory temperature (pp. 795, 726). 

Not infrequently food was served in dishes not well cleaned. 
There is no reason to doubt but that the dishes were properly steri- 
lized, but the fact that at times traces of food from a former meal 
were found upon them, was naturally repulsive, particularly to per- 
sons of delicate stomachs. 

Generally speaking, the same menu was provided for all of the 
ambulatory patients and individualization of diet was attempted, 
principally for patients in the more serious stages of the disease. 

I am not unmindful of the whimsical character of the appetites of 
persons of ill health, particularly of tubercular patients, whose appe- 
tites are notoriously notional and whose systems are incapable of 
normal assimilation. I also take into consideration the normal differ- 
ences as to likes and dislikes as to food and methods of service, and the 
utter impossibility of satisfying the appetites of 1,200 people in one 
hospital with food from any one kitchen. However, after discounting 
complaints by these considerations, as well as by any animus en- 
gendered by controversy, the evidence clearly shows that the patients 
(were supplied with unpalatable and improperly cooked food, poorly 
served. 
The objectionable character of the food was more than a mere 
violation of the taste of the patients. It substantially effected their 
comfort and the progress of their recovery. This and the querulous 
disposition of some of the patients tended to break down the morale 
of the institution. 



4 GENERAL HOSPITAL NO. 21, AT AURORA, COLO. 

Col. Harlow was at the head of the hospital from its initiation to the 
month of June, 1919. 

While the cooks and the kitchen and dining room help were di- 
rectly responsible for these shortcomings, Col. Harlow, who was in 
charge while these conditions prevailed, must be held as the one in 
responsible authority. I do not doubt the good motives or energetic 
interest of Col. Harlow 7 . His previous history seemed to justify his 
appointment, but his lack of training and military hospital experience, 
made him unequal to the task of assembling a personnel able to cope 
with the trying conditions under which this institution was inaugu- 
rated and for which the ample and satisfactory equipment was not 
available. No one could have given fully satisfactory service during 
the early months of the institution, but doubtless a more experienced 
and diplomatic head could have given more satisfactory service. He 
should have been replaced at an earlier date. 

USE OF STRAIT-JACKETS. 

Particular complaint has been made against the use of strait- 
j ackers at this institution. Hospital strait-jackets were used once 
on each of seven different men, nearly all of whom were tubercular 
patients. 

This jacket is made of strong, heavy canvas, the main part of 
which is about 7 feet long and 4 feet wide, the sides and top of which 
are surrounded by metal eyes. On the inside of this main sheet is 
a bodice that laces close to the body from the waist up. Long 
pockets are provided on the inside of the sheet into which the arms 
are inserted and the removal of which by the patient becomes im- 
possible when the jacket is drawn together by cords inserted in the 
metal eyes, connecting the sides of the bodice. The eyes in the main 
sheet furnish a method of attaching it to the sides of the bed, if 
desired (pp. 702, 789). 

The strait-jacket was first used during the month of December, 
1918, and last used on the 21st of February, 1919 (p. 772). An 
inspector from the War Department visited the hospital in the month 
of February, 1919, and his report led to an order by the Surgeon 
General prohibiting the use of the strait-jacket for punitive purposes. 

The jacket was used on Parks, Bassett, Willings, Evanko, Mor- 
cetti, and two colored men, John Macon and Charles Wilson (p. 772). 

In every instance the strait- jackets were authorized by Maj. 
William H. Bergtold, who was chief of the medical service of the 
hospital. 

Maj. Bergtold had 35 years' experience as a practicing physician 
before volunteering for the military service, in which he was com- 
missioned on the 30th of September, 191S. About 30 years of his 
life had been primarily devoted to the treatment of tubercular 
patients, at which work he has had marked success. He practiced 
for many years in the city of Denver. He had also had a wide 
experience in connection with civilian hospitals, but had no previous 
military experience (p. 773). His experience and standing as a 
physician entirely warranted his appointment. Volunteering his 
services to the Government was perhaps more or less of a personal 
sacrifice, and must be recognized as commendable. 



GENERAL HOSPITAL NO. 21, AT AURORA, COLO. 5 

Nevertheless, in ray judgment, the evidence allows no escape from 
the conclusion that the use of the strait-jacket in most instances was 
unwarranted, as well as an undiplomatic handling of the situation 
involved. 

Unquestionably the strait-jacket could have been legitimately 
used to prevent self-injury to an insane or deranged patient or to 
restrain any violent person, but in few, if any, instances was a feature 
of this kind involved. Its use was punitive. 

Patients were released from the jacket for the purpose of eating or 
other necessary purposes (p. 703). As to whether or not any actual 
specific injuries resulted from the use of the jacket, the evidence is 
conflicting (pp. 701, 703, 704, 720, 723, 769, 763, 764, 777, 793). A 
fair inference from the testimony is that in at least one, and probably 
in one or two other instances, ill consequences did result from the 
use of the jacket. 

The jacket was first used upon Evanko. Evanko brought whisky 
into the hospital, and it was claimed he was drunk. Being confined 
in the disciplinary barracks, he later refused to remain in bed as 
ordered according to the rules, and also persisted in talking in viola- 
tion of the rules. Part of his troubles grew out of a claim that a 
pocket book of another party, of which he gained possession on account 
of borrowing the other's clothes, was owned by himself (pp. 847, 849). 
He was not under the influence of liquor at the time he was placed 
in the jacket. His conduct was insubordinate. Evanko was suf- 
fering from tuberculosis. He did not sleep while wearing the jacket 
and was depressed and restless. He was sick following the removal 
of the strait-jacket (pp. 723, 788-789). 

Parks, a tubercular patient, was placed in the strait-jacket on the 
24th of January, 1919. This patient was five times confined in the 
disciplinary ward on charges of absence without leave. He left the 
hospital on the 11th of January and visited Denver. He remained 
without leave until the 21st of January. In the meantime he con- 
tracted the flu and returned to the hospital in a convalescent condi- 
tion with a fever of 100.8. He used insulting and abusive language 
toward the officer in charge, as a result of which he was ordered into 
the strait- jacket, in which, excepting for minor interruptions, he was 
confined from 7.30 in the morning until 1 o'clock the next day. In 
the early morning of the following day, Parks had a hemorrhage, 
which he claims was followed by three other hemorrhages during 
the succeeding days. A claim was made that the hemorrhage was 
caused by a self-inflicted wound in the nose (pp. 799, 778). In my 
judgment, the fair conclusion from the testimony is that he suffered 
from pulmonary hemorrhages not superinduced (pp. 720-721). The 
clinical record of this patient fails to show a hemorrhage or any 
abnormal condition, indicating that confinement in the strait-jacket 
produced ill consequences (pp. 764-766, 777). This patient had 
previously suffered from a hemorrhage, but not subsequently to 
the time involved here. In view of the fact that hemorrhage may be 
induced by exertion, physical restraint, and nervous or mental 
agitation, it may fairly be concluded that the use of the jacket was 
a contributing cause to the hemorrhage. 

In my judgment the use of the strait-jacket on Parks and Evanko 
was unwarranted. The conduct of each was provoking, but those 
fit to be in charge of public hospitals should have the magnanimity 



6 GENERAL HOSPITAL IS T 0. 21, AT AURORA, COLO. 

and patience necessary to overlook the peevishness and unreason- 
able and insulting conduct of sick men. If additional punishment 
was necessary, some less distressing method should have been 
employed. 

The others on whom strait-jackets were used suffered no ill con- 
sequences (pp. 771, 777). Macon had threatened an assault with a 
knife (pp. 800, 770-771,792). Wilson was in a fight (p. 792). Willing* 
and Bassett had committed only trivial offenses, which could have 
been adequately punished by confinement (pp. 722-723, 706-707). 

NEGLECT. 

Particular charges of neglect have been made in reference to a 
patient named Pinkham, whose chance of recovery was hopeless. 
The condition of this patient made him incapable of assimilating 
food in any satisfactory manner. His appetite was abnormal, his 
condition was irritating and distressing. He was finally furnished a 
special nurse, and while lacking the personal attention that a home 
or private institution might give, I do not feel the evidence warrants 
a condemnation of the hospital management on his account (pp. 862, 
836, 754-762, 781). 

DISTRIBUTION OF FOODS FROM OUTSIDE. 

Complaints were made against the rule established by the hospital 
authorities which prohibited the bringing in and distribution of foods 
and delicacies from the outside without the consent of the hospital 
authorities. It must be conceded that such a rule is a proper one. 
Evidently one or more persons with good intentions thought the rule 
was arbitrarily applied. No specific evidence has been presented 
which adequately supports this charge. 

DISCIPLINARY WARD. 

Two rules governing patients in the disciplinary ward have been 
criticized. One rule prohibited persons confined therein from con- 
versing with each other and the other required such persons to 
remain in bed, except for necessary purposes or with consent of 
the guards. In my judgment," these rules unnecessarily restricted 
the liberties of the patients. Strictness in enforcing these roles was 
abrogated several months prior to this investigation and patients 
in the disciplinary barracks are now permitted to talk to each other 
in moderate tones and are permitted to move about in the ward 
and are not confined to beds for punitive purposes. 

A degree of enforced rest and silence was required of all the pa- 
tients, whether in the disciplinary barracks or elsewhere. It is 
possible that the forced quiteness and rest imposed upon patients 
m the disciplinary barracks on the whole more than compensated 
them for the extreme enforcement of the above-mentioned rules. 
Nevertheless, these rules were originally enforced in a punitive way 
and were unreasonable in extent and beyond what the welfare of 
the patients required. 

Confinement in the disciplinary barracks was not in itself any 
particular hardship. The institution had no lock-up or padded cells 
or cages or in fact any room which in itself was sufficient to confine 



GENERAL HOSPITAL NO. 21, AT AURORA, COLO. 7 

a man therein if he desired to escape by force. The guards were 
unarmed and the same general arrangement for the accommodation 
of tubercular patients prevailed in the disciplinary wards as in other 
portions of the hospital. Outside of the confinement therein, the 
only other particular feature in the nature of punishment imposed 
in addition to those above mentioned was the denial of the use of 
tobacco. 

The records of the institution show that the total number of 
persons confined in the disciplinary barracks since the establishment 
of the hospital up to the 25th of September, 1919, was 342. Quite 
a number of the persons committed to the disciplinary wards were 
sent there for therapeutic reasons and not for punitive purposes. 

Some men sent to the barracks repeated their offenses a number 
of times; in some instances as many as five times. 

The maximum sentences imposed were 90 days with one-third off 
for good behavior. 

Forty-eight was the largest number of persons confined in the 
barracks at one time. 

The sentences imposed, though sometimes for trivial reasons, do 
not appear to have been unreasonably severe. 

PASSES. 

Refusal of passes was the source of more or less dissatisfaction 
among the patients. The granting of passes caused more or less 
trouble to the hospital management and not infrequently ill conse- 
quences to the patients, who failed to take proper care of themselves 
during their absence. The agitation of the question of passes among 
the patients promoted something of rebellious spirit. The matter 
was a source of irritation among the patients in the institution, 
rather than of substantial importance in itself. 

In the case of one Pucka, a more or less arbitrary attitude was 
assumed by some subordinate officers of the institution, that showed 
a lack of alertness and indifference in the treatment of an inmate 
that was at least inconsiderate if not an abuse of power. Pucka 
had committed a trivial offense on account of which he was delayed 
in securing a pass to meet his mother at the train, who was coming 
to see him from a distance of 600 or 700 miles. Upon his return, 
he was sent to the disciplinary barracks as a punishment for the 
offense committed several days before. Upon the appearance of 
his mother next day, she was for some time denied the privilege of 
seeing him and was later permitted to see him only for a brief period. 
This barrier was removed during the succeeding days, however. 
Finally, on receiving a telegram that his father was seriously injured, 
the truthfulness of the message was distrusted and a delay of 12 
hours occurred before the son was permitted to leave the institution 
for home. For that reason he was unable to accompany his mother 
in the time of her distress, the father having died before the mother 
and son arrived. 

Prior to the present management, which took hold of this institu- 
tion in June, its affairs were entirely in charge of those engaged in 
civilian employment until after America entered the war. The 
control of the patients was in the hands of those unused to the power 
that military authority gives. 



l_lDI\t-irs. 1 



GENERAL HOSPITAL NO. 21, AT AURORA, 



PRESENT CONDITIONS. 



Hill Mill Hill "in lira in ' "»■ him ■»•■;»■— - 

020 913 354 4 



This hospital under its present management has been investigated! 
by representatives of both the Loyal Legion and the Masons. Their 
reports have been favorable (pp. 845, 850, 861). 

What has been said herein must not be accepted as a wholesale 
condemnation of General Hospital No. 21. Notwithstanding these 
criticisms, on the whole it has performed a splendid work and has 
restored many soldiers to health and helped many others. Matters, 
here criticized hampered the success of its work, but did not defeat 
the main purpose of the institution. The most serious faults of the 
institution were confined to its earlier months. The managerial 
personnel was changed some months ago. 

Since that time Col. Howard H. Johnson has been in charge. He 
had a wide and useful experience at military hospitals before and 
during the war. 

Some time ago he established a practice at the institution of 
inviting complaints and suggestions from any patients about hospital 
matters. His disposition to meet with and consider the needs of the 
patients has greatly improved the morale of the institution and is an 
example worthy of emulation by military men in similar authority. 

This institution necessarily began its work with an inexperienced 
and more or less incompetent personnel. Conditions have greatly 
improved (pp. 698, 713, 728, 729, 767, 785, 795-797, 814, 816, 823, 
829, 833, 835, 837, 843, 845, 849, 850, 851-853). 

Labor troubles and unavoidable delays in securing proper equip- 
ment for the institution materially contributed to the difficulties with 
which the management has had to contend from the beginning. 

The mistakes made in the management of this institution are 
regrettable, but at the present there is every reason to expect good 
service and good results. 

Clarence F. Lea. 



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